UWORLDNCLEX-RN test 1 Latest Updated Graded A+

Document Content and Description Below

A nurse in the intensive care unit is caring for a client in the immediate postoperative period following abdominal surgery. The nurse receives several prescriptions. Which prescription should the nur... se initiate first? Click on the exhibit button for additional information. - ANSWER Normal saline 2 L via rapid IV bolus. A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond? - ANSWER Refer employee to the employee health provider. The school nurse assesses an 8-year-old with a history of asthma. The nurse notes mild wheezing and coughing. Which action should the nurse perform first? - ANSWER Assess the client's peak expiratory flow. A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client most likely suffers from which psychological disorder? - ANSWER Agoraphobia A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by the nurse promotes a therapeutic relationship? - ANSWER "People with cancer experience fear of dying; tell me about your concerns." The nurse is reinforcing education to the caregivers of a 9-year-old client diagnosed with scarlet fever. The client has a history of type 1 diabetes mellitus. Which statement by the caregivers indicates that further teaching is needed? - ANSWER "We will not administer insulin if our child is unable to eat." A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for care at home? Select all that apply. - ANSWER 1. Apply a patch to the right eye at night. 3. Chew on the left side. 4. Maintain meticulous oral hygiene. - Bell's palsy is an inflammation of the cranial nerve VII (facial) that causes motor and sensory alterations. Clients are usually managed as outpatients, with corticosteroids to reduce inflammation, and taught eye/oral care. In Bell's palsy, the eyelids do not close properly. This may result in eye dryness and risk of corneal abrasions. However, weakness of teh lower eyelid may cause excessive tearing due to overflow in some clients. Facial muscle weakness results in poor chewing and food retention. The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What initial action should the triage nurse take? - ANSWER Place the client in an inside hallway with one-on-one observation. The orthopedic health care provider instructs a client with a fractured femur, who has been non-weight bearing for the past 5 weeks, to progress to full weight bearing on the right leg. which advanced crutch gait that most closely resembles normal walking should the office nurse teach the client? - ANSWER 4-point gait - there are 5 crutch gaits: 2-, 3-, 4-point, swing-to, and swing-through `A nurse administers an intramuscular (IM) injection using the Z-track method technique. Place the steps in chronological order. All options must be used. - ANSWER 4. Pull the skin 1-1 1/2" (2.5-3.5 cm) laterally and away from the injection site. 3. Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle. 2. Inject medication slowly with dominant hand while maintaining traction 6. Wait 10 seconds after injecting the medication and withdraw the needle. Release the hold on the skin, allowing the layers to slide back to their original position. 1. Apply gentle pressure at the injection site but do not massage. The clinic nurse is teaching a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism. Which statement made by the client indicates that further teaching is needed? - ANSWER "If this makes my stomach upset, I will take it with an antacid." - will impair the absorption of levothyroxine (Synthroid). -- Antacids, calcium and iron preparations. - should take levothyroxine on an empty stomach, preferably in the morning, separately from other medications The nurse is reviewing laboratory results for several prenatal clients. Which finding is most important to report to the health care provider? - ANSWER Client at 24 weeks gestation with hemoglobin of 9 g/dL (90 g/L) and hematocrit of 29% - during the second half of pregnancy, the fetus beings to store iron, depleting maternal stores. Hemoglobin <11 g/dL in the first or third trimester or <10.5 g/dL in the second trimester is considered low. A client with obesity has just started taking orlistat. Which statement by the client indicates a need for further teaching? - ANSWER "I have started taking a daily multivitamin with my dinner-time dose of medication." - Orlistat is a lipase inhibitor that prevents the breakdown and absorption of fats from the intestine - interferes with fat-soluble vitamin uptake The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants immediate attention? - ANSWER Client with epigastric pain after endoscopic retrograde cholangiopancreatography. - Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-threatening complication after an ERCP: s/s - acute epigastric or left upper quadrant pain, often radiating to the back, and a rapid rise in pancreatic enzymes (amylase. lipase) The home health care nurse reviews the laboratory results for 4 clients. Which laboratory value is most important for the nurse to report to the health care provider? - ANSWER Client with rheumatoid arthritis taking adalimumab has a WBC count of 14,000/mm3 Which emergency department client would be allowed to leave against medical advice after the risks are discussed with the primary health care provider? - ANSWER Client with coffee-ground emesis from chronic use of high-dose aspirin. - Issues that can make a client ineligible to leave AMA include danger to self or others, lack of consciousness, altered consciousness, mental illness, being under chemical influence, or a court decision. Parents may not refuse life-, limb-, or organ- saving treatment on behalf of their minor child for religious or personal reasons: if the parents deny critical treatments to the child, the hospital may seek protective custody Which of the following are examples of medical battery? Select all that apply. - ANSWER 3. The nurse administers 2 mg of morphine PRN to a difficult, alert client but tells the client it is saline. 4. The nurse inserts a needed urinary catheter even though a competent client refuses it The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription? - ANSWER Sucking lip motions. - Metoclopramide is a commonly used antiemetic medication that treats nausea, vomiting, and gastroparesis by increasing gastrointestinal motility and promoting stomach emptying. With extended use and/or high doses, metoclopramide may lead to the development of tardive dyskinesia, a movement disorder that is characterized by uncontrollable motions and is often irreversible. Clinical manifestations of tardive dyskinesia: Facial - ANSWER - Lip movement - smacking, sucking, puckering - tongue movement - protrusion, curling - grimace - brow furrow or twitch - excess blinking Clinical manifestations of tardive dyskinesia: extremities - ANSWER - foot tap - hand wringing - tremor or shake Clinical manifestations of tardive dyskinesia: neck and torso - ANSWER - rocking - torticollis - persistent neck flexion or extension A client admitted 3 days ago with upper gastrointestinal bleeding underwent an endoscopic procedure to stop the bleeding. The client is started on a clear liquid diet today. Which foods are appropriate for the nurse to offer the client. Select all that apply. - ANSWER 1. Apple juice 3. Chicken broth 5. Unsweetened tea The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? Select all that apply. - ANSWER 1. Area around the insertion site feels cool to the touch 3. Edema is observed on the dependent side of the involved arm 5. Serous fluid leaks from the site despite secure connections The nurse is monitoring a client who is 6 cm dilated with recurrent variable decelerations on the fetal heart rate monitor. The health care provider (HCP) places an intrauterine pressure catheter and prescribes an amnioinfusion. After the amnioinfusion bolus is complete, which assessment finding should the nurse report to the HCP immediately? Click the exhibit button for additional information. - ANSWER Uterine resting tone baseline has increased to 45 mm Hg and perineal pads are dry - Amnioinfusion is a transvaginal infusion of isotonic fluids through an intrauterine pressure catheter to compensate for ow amniotic fluid in the uterus. During labor, an amnioinfusion is indicated to relieve persistent, recurrent variable decelerations caused by umbilical cord compression. - a potential complication is uterine overdistention due to infusion of too much fluid. - if uterine resting tone is elevated and minimal to absent fluid return is noted, the nurse should pause the infusion and notify the HCP An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired. Select all that apply. - ANSWER 2. Burping the infant often. 3. Feeding in an upright position 5. Using a specialty bottle or nipple The clinic nurse is assessing a previously healthy 60-year-old client when the client says, "My hand has been shaking when I try to cut food. I did some research online. Could I have Parkinson's disease?" Which response from the nurse is the most helpful? - ANSWER "Tell me more about your symptoms. When did they start?" A laboring client weighing 187 lb is 5 cm dilated and having contractions every 20=-3 minutes. The client rates the pain at 7 out of 10. Nalbuphine hydrochloride 10 mg/70 kg IV push x 1 is prescribed by the health care provider. Nalbuphine hydrochloride 10 mg/1 mL is available. how many milliliters does the nurse administer? - ANSWER 1.2 A nurse is discussing the concept of parallel play with parents of toddlers. Which statement should the nurse include to describe this type of play? - ANSWER "Children play near other children but without significant interaction." [Show More]

Last updated: 1 year ago

Preview 1 out of 12 pages